Analysis Pre-Departure Passage Plan There is a combined responsibility by the navigating officer and the acting master to ensure safe navigation at all times. This is normally reinforced by adherence to a pre-departure passage plan that outlines the courses to steer, the speed of the vessel with respect to squat, shallow areas to be avoided, ranges to be kept in-line and pre-set short chronological time periods for position plotting. No pre-departure passage plan was in place at the time the CanadianTransfer left the dock to ensure the vessel's safe passage in deeper waters. On clearing the dock, a lead-up course of 272would bring the vessel onto the ranges and the course would be altered to between 266and 267to maintain the recommended track which would take the vessel clear of the harbour and approaches. This course adjustment was not made and the vessel was allowed to progress further to the north, eventually striking bottom. Given the sophistication of the navigational systems of the vessels calling at the port and the relatively simple approach/departure, the buoys that had marked channel limits were not considered cost-effective after commercialization and were removed. In calm conditions, an ideal vessel movement from Goderich Harbour would normally entail few course changes and should not have presented any difficulty. The ideal weather conditions and the simplicity of the vessel movement resulted in a casual approach to navigation. This is reflected in the vessel's position not being closely monitored during the critical period of the vessel's departure and while navigating in the narrow channel. As there was no passage plan, the bridge team was deprived of a means that would have helped it to remain focussed on the safe navigation of the vessel. Bridge Resource Management - Non-Navigating Duties and Personnel Availability BRM is considerably restricted when the bridge team is only the master and a wheelsman. Such was the case when the CanadianTransfer departed the salt dock in Goderich Harbour. Verification of courses and monitoring of the vessel movement along a safe path using BRM principles are more readily accomplished with an additional navigating officer. On 13 April 2001, the General Manager, Operations, for the Upper Lakes Group Inc. issued circular letter24-2001 which was addressed to all masters and deck officers for awareness and education. The letter brought attention to the TSB publication Safety Reflexions: Marine detailing recent marine investigations, particularly the investigation of the OlympicMentor (TSBReportNo.M95C0120). It emphasized the importance of effective BRM which supports the informed navigation decision process of a master/pilot by all bridge team members. When the OOW arrived on the bridge, he was immediately assigned the task of formulating the estimated time of arrival for mid-lake; a low-priority navigational task. Once this task was completed, the OOW stood by the forward bridge chart table. He did not plot the vessel's position nor did he verify the vessel's position, either by ECPINS, radar range and bearing, the Differential Global Positioning System, or by visual means such as alignment of the ranges astern. Instead, he made an incorrect assumption that the relief master was conducting the vessel safely to open waters. The time when risk is typically the highest is on arrival or departure from port. However, the common practice on the Great Lakes is for the duty officer to carry out non-navigational tasks and freshen up before returning for bridge duty. In this instance, the OOW spent some 10to 15minutes to freshen up before proceeding to the bridge. Further, although two masters were on board, only the relief master was on the bridge. The presence of an officer / additional master on the bridge during departure dedicated to the navigation of the vessel could have increased the synergy of the bridge team. This would lead to early identification of navigational errors or developing situations to be communicated to the master for timely remedial measures. Effective Use of Navigation Equipment and Navigational Aids The bridge navigation equipment on board the CanadianTransfer was not used to advantage. The ECPINS on board the vessel was using a vector chart of Goderich Harbour. Electronic Navigation Charts (ENCs) particularly in Vector format, offer a range of alarm and indicators for route monitoring. They serve to bring the situation to the attention of the OOW so that he can intervene as required. For instance, the system can be used to determine safety parameters such as draught, cross-track error and any other relevant features as long as they are pre-set by the OOW. During the course of a voyage, the ECPINS records the ship's course changes and systematically scans vector chart data comparing variations progressively with the pre-set safety parameters. An alarm will be triggered when any of the pre-set safety limits are violated. ECPINS can display an anti-grounding cone. This anti-grounding lookahead cone can look forward and around the next waypoint where the route bends. To display the anti-grounding cone, the OOW must enter the desired parameters. Once the values are set, the anti-grounding cone must be enabled. The Port and Starboard Extension fields add a minimum safety width to each side of the own ship. The Stern defines the base of the cone. The Bow field adds a minimum safety distance ahead of the bow. These features cannot be used with a raster chart. Electronic chart systems such as ECPINS, as well as IMO type-approved Electronic Chart Display and Information System (ECDIS), all provide alarms or indicators when using automatic track control. Using appropriate limits (vectors as safe ship boundaries), the alarms or indicators would be triggered if: The pre-set cross track limit from the planned route is exceeded; The ship is within a pre-set time limit or distance from a critical point along the planned route (e.g. from wheel-over line for the next course change); The route pre-set maximum course difference between the planned route and gyro indicator is exceeded. The system was functioning satisfactorily but was not used to advantage to safely navigate the vessel. The set of ranges in Goderich Harbour was accurate, but the bridge team did not keep the vessel in line, even after the relief master noticed the vessel crossing the projected line from south to north. Speed of the Vessel and Squat As a vessel moves ahead in a shallow channel, the flow of water under the hull is accelerated and causes a reduction in pressure, such that the vessel settles deeper than its static mean draught. This phenomenon is known as squat and is dependent on the vessel's speed, the ratio of its static draught to the channel depth, and the relationship of the cross-sectional areas of the hull and the channel. The squat depth increases proportionately with the square of the speed, and loaded vessels with limited under-keel clearance (UKC), when proceeding at too high a speed, may settle, make bottom contact and incur grounding damage. Observation and analysis of several hundred vessels operating at various speeds in relatively shallow water indicate that dry-bulk carriers similar to the CanadianTransfer, having block coefficients (Cb) of about 0.800,tend to settle bodily and squat more by the bow.2 At the time of the occurrence, the water levels in Lake Huron reportedly were 0.08m lower than the published charted depths. Consequently, when the vessel entered an area shown to have a depth of 8.23m, the actual water depth was8.15m. The vessel's forward and after loaded draughts were recorded as 7.34m and 7.625m, respectively, which, together with a mean draught of approximately 7.48m, indicate a ratio of water depth to mean static draught of approximately 1.10and a related static UKC of 0.67m as the vessel entered the shallower area. However, in these conditions, a speed of 11.4knots would cause the vessel to squat approximately 1.10m which, being in excess of the static UKC, resulted in the vessel making bottom contact. Because of its full form and a speed of 11.4knots, the vessel would squat and tend to trim by the bow when entering the shallower water. Such characteristics are consistent with the location of the bottom shell damage actually incurred at the forward end of the vessel. Reportedly, when loaded Great Lakes vessels depart Goderich Harbour, they routinely employ speeds of six to seven knots. It may be noted that, when similarly loaded to the same draughts, the CanadianTransfer would have incurred squats of 0.29m to 0.39m at these speeds, and that bottom contact would most likely have been avoided. Conduct of the Vessel and Safety As the relief master was unsupervised on the bridge, this would suggest that the permanent master had confidence in the relief master's abilities to pilot the vessel out of the harbour. The fact that the relief master did not request the presence of the permanent master on the bridge would suggest that he had confidence in his own abilities to pilot the vessel out of GoderichHarbour. the vessel's progress not being closely monitored; no corrective action being taken by the relief master to keep the vessel on a safe track although he was aware that the vessel had crossed the range line from south to north; minimal communication between bridge personnel; the bridge team functioning in a non-cohesive manner; and the tasks assigned to the officer of the watch not being prioritized. the vessel's progress not being closely monitored; no corrective action being taken by the relief master to keep the vessel on a safe track although he was aware that the vessel had crossed the range line from south to north; minimal communication between bridge personnel; the bridge team functioning in a non-cohesive manner; and the tasks assigned to the officer of the watch not being prioritized. The electronic instruments for navigation, especially the electronic chart precise integrated navigation system, were under-utilized. The anti-grounding feature, with which the bridge team was familiar and which could have given warning of an impending grounding, was not used. Forward bottom shell damage was incurred because the under-keel clearance was lost due to shallow water squat and trimming effects caused by the vessel's speed of 11.4knots.Findings as to Causes and Contributing Factors the vessel's progress not being closely monitored; no corrective action being taken by the relief master to keep the vessel on a safe track although he was aware that the vessel had crossed the range line from south to north; minimal communication between bridge personnel; the bridge team functioning in a non-cohesive manner; and the tasks assigned to the officer of the watch not being prioritized. the vessel's progress not being closely monitored; no corrective action being taken by the relief master to keep the vessel on a safe track although he was aware that the vessel had crossed the range line from south to north; minimal communication between bridge personnel; the bridge team functioning in a non-cohesive manner; and the tasks assigned to the officer of the watch not being prioritized. The electronic instruments for navigation, especially the electronic chart precise integrated navigation system, were under-utilized. The anti-grounding feature, with which the bridge team was familiar and which could have given warning of an impending grounding, was not used. Forward bottom shell damage was incurred because the under-keel clearance was lost due to shallow water squat and trimming effects caused by the vessel's speed of 11.4knots. Both the master and the relief master had confidence in the latter's ability to pilot the vessel out of Goderich Harbour.Other Findings Both the master and the relief master had confidence in the latter's ability to pilot the vessel out of Goderich Harbour. The owners of the vessel have re-inforced safety aspects as follows: ECDIS or ECDIS equivalent equipment is fitted on all company ships and all masters and 1stofficers have received formal ECDIS and BRM training. In addition, 2nd and 3rdofficers have received in-house abbreviated BRM training. TSB investigation reports and magazine Reflexionscontinue to be routinely forwarded to company vessels for required reading and review by officers. BRM occurrences are highlighted for emphasis. Pre-arrival and pre-departure checklists, which include the requirement for passage plans, are mandatory and are in place under company standard procedures.Safety Action Taken The owners of the vessel have re-inforced safety aspects as follows: ECDIS or ECDIS equivalent equipment is fitted on all company ships and all masters and 1stofficers have received formal ECDIS and BRM training. In addition, 2nd and 3rdofficers have received in-house abbreviated BRM training. TSB investigation reports and magazine Reflexionscontinue to be routinely forwarded to company vessels for required reading and review by officers. BRM occurrences are highlighted for emphasis. Pre-arrival and pre-departure checklists, which include the requirement for passage plans, are mandatory and are in place under company standard procedures.